kpmle2
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A 78-year-old woman with a history of systolic hypertension and chronic obstructive pulmonary disease presents with progressive shortness of breath over the past 6 months. She notes dyspnea walking across the room and she has begun waking up at night coughing. She has increased use of her inhaler without any improvement. She denies fever and chills. Her outpatient medications include amlodipine 10mg daily, hydrochlorothiazide 12.5 mg daily, prednisone 5mg daily, and albuterol inhaler. Her social history is notable for a single glass of wine a day and no prior history of smoking. Her blood pressure is 145/70 mm Hg and her heart rate is 82/min. On examination, she has mild jugular venous distension. She has clear lung fields. She has a regular rhythm, a grade 2/6 holosystolic murmur at the apex, and no S3. Laboratory data include a normal complete blood count, serum sodium 138 mg/dL, potassium 3.8 mg/dL, glucose 95 mg/dL, and creatinine 1.4 mg/dL.
Chest radiograph shows mild cardiomegaly with mild increase in interstitial markings but no infiltrates. An electrocardiogram shows normal sinus rhythm and left ventricular hypertrophy. Her pulmonary function tests show a mixed restrictive and obstructive pattern. An echocardiogram shows concentric hypertrophy, left atrial enlargement, a left ventricular ejection fraction of 65%, and moderate mitral and tricuspid regurgitation.
Which of the following is the most likely cause of this patient’s dyspnea and nocturnal cough?
A. Pneumonia
B. Worsened chronic obstructive pulmonary disease
C. Heart failure
D. Acute coronary syndrome
E. Pulmonary fibrosis
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| neuroblastoma
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B. Worsened chronic obstructive pulmonary disease
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| Vietnamese
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Why not C ? She can had Diastolic Heart Failure.
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| tamerbashir
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B
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| RX 135
tormenta
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C
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| drduck
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very nice Q.
hmm.....i m confused between...COPD and HF
i will go with HF.....
parox noct dyspnea,
other finding point more towards cardiac lesion.
but not sure.
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| cool doctor
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nice one
although physical exam dosnt go with HF but I dont know why I feel it is HF.
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| mediocre
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HF 2ndry to worsening valve lesion
Points for HF= raised jvp , orthopnea, cardiac asthma, mod-low lvfunction
although clear lung fields go against it
Points against COPD exacerbation= no sputum, no inflamatory markers
mixed restrictive/obstr defect is due to chronic amlodipine and previous copd
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| Ivonne
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Have changed  my mind will go with diastolic dysfunction---------->C
Does diastolic dysfunction give a restrictive pattern in pulmonary function tests?
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| sandra
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whts the answer kpmle?
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| drshvetasm
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C
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| Korotkoff
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sure C.
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| kpmle2
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The correct answer is C
Recognize diastolic dysfunction as a cause of heart failure symptoms.
This patient presents with heart failure due to diastolic dysfunction. The patient’s symptoms of dyspnea with exertion create a broad differential diagnosis. The nocturnal cough suggests heart failure is a more likely cause. She has risk factors for heart failure by virtue of her age and history of systolic hypertension. Her electrocardiogram shows left ventricular hypertrophy. The echocardiogram shows normal systolic function and it is not uncommon for there to be no description of diastolic function parameters as in this case. However there were moderate mitral regurgitation and left atrial enlargement, findings consistent with elevated left ventricular filling pressures. When heart failure is chronic, the examination of the lung fields commonly does not reveal rales, due to dilation of pulmonary lymphatics. The patient never smoked and the prior diagnosis of chronic obstructive pulmonary disease is perhaps a misclassification of heart failure symptoms. An acute coronary syndrome would not present with worsening over 6 months. Pulmonary fibrosis is a possible diagnosis but less common than heart failure and would not explain the left-sided findings on the echocardiogram. The B-natriuretic peptide assay may have been helpful in establishing the diagnosis in this case. If the B-natriuretic peptide result was <100 pg/mL, the diagnosis would be unlikely to be heart failure. In this case the B-natriuretic peptide result would be expected to be in the 400 to 600 pg/mL range.
Management would include administration of a loop diuretic, the addition of an ACE inhibitor and β-blocker to her regimen, discontinuing prednisone with taper, and discontinuing the albuterol inhaler.
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